Provider Demographics
NPI:1770822769
Name:REYES, TAMMY (CNM)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:REYES
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15110 JOHN J DELANEY DR
Practice Address - Street 2:STE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3544
Practice Address - Country:US
Practice Address - Phone:704-512-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-11
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC269868367A00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0001190372OtherNURSING LICENSE
MD0646521100Medicaid
NC1770822769Medicaid
SCMW0223Medicaid
NCQ481847165Medicare PIN
MD0646521100Medicaid
NCQ46708AMedicare PIN